By Josh Sanburn
September 4, 2014

Updated: 3:40 p.m E.T. on Sept. 4

An improperly placed IV and inadequate executioner training led to the botched execution of Oklahoma death row inmate Clayton Lockett in April, according to a state report released Thursday.

According to the review conducted by the Oklahoma Department of Public Safety, an IV placed in Lockett’s groin became dislodged during the execution, causing the area where the IV had been placed to swell to a size “smaller than a tennis ball, but larger than a golf ball.” The improper insertion allowed the first drug administered, a sedative called midazolam, to leak into the surrounding tissues rather than enter Lockett’s vein. It took 51 minutes for executioners to find a vein to administer the execution drugs and another 43 minutes before Lockett was pronounced dead.

Executioners used Lockett’s groin after failing multiple times to insert the IV into his arms, feet and neck. The report found that the corrections officers who carry out Oklahoma’s executions only receive formal training from paramedics on the day of the scheduled killing and operate without contingency measures in the event something goes wrong.

The review was ordered by Oklahoma Governor Mary Fallin after Lockett’s prolonged execution on April 29 led to a public outcry and a renewed national debate over capital punishment. Lockett was sentenced to die for the 1999 murder of Stephanie Neiman.

The report offers several recommendations, including making the IV insertion point visible at all times (Lockett’s groin was covered by a sheet); establishing formal training programs for those involved in executions; requiring adequate back-up drugs and contingency plans, and scheduling only one execution a week. Oklahoma had planned to execute another inmate, Charles Warner, later that day but postponed it following Lockett’s lethal injection. The back-t0-back executions had put extra stress on the corrections officers charged with carrying them out, according to the report.

The report does not fault any state officials for the prolonged execution, a point some critics have seized on.

“The state’s internal investigation raises more questions than it answers,” said Dale Baich, a lawyer who represents Oklahoma death row inmates, in a statement. “The report does not address accountability. It protects the chain of command. Once the execution was clearly going wrong, it should have been stopped, but it wasn’t. Whoever allowed the execution to continue needs to be held accountable.”

Contact us at editors@time.com.

SPONSORED FINANCIAL CONTENT

Read More From TIME

EDIT POST